Thrombocytopenia vancomycin

WARNING Renal impair is the major tox foUow administration instructions Uses CMV retinitis w/ HIV Action Selective inhibition of viral DNA synth Dose Rx 5 mg/kg IV over 1 h once/wk for 2 wk w/ probenecid Maint 5 mg/kg IV once/2 wk w/ probenecid (2 g PO 3 h prior to cidofovir, then 1 g PO at 2 h 8 h after cidofovir) X in renal impair Caution [C, -] Contra Probenecid or sulfa allergy Disp Inj SE Renal tox, chills, fever, HA, NA /D, thrombocytopenia, neutropenia Interactions t Nephrotox W/ aminoglycosides, amphot icin B, foscar-net, IV pentamidine, NSAIDs, vancomycin t effects W/zidovudine EMS Monitor ECG for hypocalcemia (t QT int val) and hypokalemia (flattened T waves) OD May cause renal failure hydration may be effective in reducing drug levels/effects Cilostazol (Pletal) TAntiplatelet, Arterial Vasodilator/ Phosphodiesterase Inhibitor] Uses Reduce Sxs of intermittent claudication Action Phosphodiesterase in inhibitor t s cAMP in pits blood vessels, vasodilation inhibit pit aggregation Dose 100 mg PO bid, 1/2 h before or 2 h after breakfast dinner Caution [C, +/-] Contra CHE, hemostatic disorders. 

Reports of drug-induced thrombocytopenia have been systematically reviewed (1). Among the 98 different drugs described in 561 articles the following antibiotics were found with level I (definite) evidence co-trimoxa-zole, rifampicin, vancomycin, sulfisoxazole, cefalothin, piperacillin, methicillin, novobiocin. Drugs with level II (probable) evidence were oxytetracycline and ampicillin. 

The most common adverse events associated with teicoplanin are hypersensitivity, fever, rash, diarrhea, nephrotoxicity, and thrombocytopenia (12,13). Local reactions at the injection site include pain, redness, or discomfort after intramuscular injection, or phlebitis after intravenous injection. Erythroderma has occurred during infusion of teicoplanin with fever and hypotension. Allergic reactions have been reported with teicoplanin, with cross-reactivity between teicoplanin and vancomycin documented by in vitro studies showing IgE release by basophils in response to stimulation by both vancomycin and teicoplanin. However, known hypersensitivity to vancomycin is not a contraindication to teicoplanin. Tumor-inducing effects have not been reported. 

In trials in the USA, thrombocytopenia occurred more commonly with teicoplanin than with vancomycin, but this was almost exclusively in patients who received much larger doses than are now recommended. 

A 14-month-old girl with chronic renal insufficiency due to renal dysplasia was empirically treated with ceftazidime and vancomycin for fever. Her calculated creatinine clearance was 10 ml/minute/1.73 m. She erroneously received vancomycin 1.5 g in 3 doses 6 hours apart. Her serum creatinine concentration increased and her vancomycin concentrations remained markedly high (338 mg/1 5 hours after the third dose). The half-Ufe of vancomycin was 145 hours. Hearing loss developed. Continued charcoal hemoperfusion and hemodialysis were used to treat the disorder. Thrombocytopenia was noted as significant consequence of hemoperfusion. The patient did not fully recover her previous renal function and became dialysis dependent. The audiogram normalized by 6 months. 

A 43-year-old white woman was given vancomycin for a suspected methicillin-resistant S. aureus infection (41). On day 10 she developed a fever, chills, and a disseminated lacy macular rash. Vancomycin was withdrawn but reinstituted 48 hours later. Another 24 hours later, she again developed a fever, chills, and a confluent erythematous rash. Sepsis developed, and ceftazidime was added. There was thrombocytopenia (118 x 10 /1), and a fall in the white blood count (from 7.6 to 3.5 X 10 /1) and hemoglobin (from 13.8 to 12.2 g/dl). One day later the leukocyte count was 2.6 x 10 /1 and the hemoglobin fell to 10 g/dl. Both drugs were withdrawn. The rash disappeared, the temperature returned to normal, and the blood cell counts completely recovered 4 days later. 

Vancomycin-associated thrombocytopenia has been reported in a 72-year-old woman who was treated with gentamicin and vancomycin for infectious endocarditis due to Clostridium pseudodiphtheriticum (52). On the 4th day of treatment, the platelet count fell and reached a nadir of 14 x lO /l on day 7. Two days after withdrawal of vancomycin (day 8) the platelet count began to rise and reached 150 x lO /l within 5 days. Vancomycin-dependent antiplatelet IgG antibodies were not detected 10 days after vancomycin. 

Thrombocytopenia also developed in a 72-year-old man who was treated with vancomycin for staphylococcal sepsis after treatment with gemcitabine for metastatic pancreatic cancer (53). On day 12 thrombocytopenia developed, reached a nadir on day 18 (13 x lO /l), and did not respond to platelet transfusions. Bone-marrow megakaryocjrtes were adequate. Platelet-associated IgG and IgM were increased. Vancomycin was withdrawn on day 28, with prompt recovery of the platelet count to 136 x lO /l in 10 days. 

Vancomycin was associated with subsequent thrombocytopenia in a retrospective study that included 193 patients in a surgical trauma intensive care unit (54). 

Kuruppu JC, Le TP, Tuazon CU. Vancomycin-associated thrombocytopenia case report and review of the literature. Am J Hematol 1999 60(3) 249-50. 

Govindarajan R, Baxter D, Wilson C, Zent C. Vancomycin-induced thrombocytopenia. Am J Hematol 1999 62(2) 122-3. 

Immunologic A 47-year-old woman developed a drug-induced hypersensitivity syndrome, rarely associated with teicoplanin, after receiving teicoplanin for 10 days [48 ]. She developed fever, lymphadenopa-thy, myalgia, raised aminotransferases and CRP, and mild neutropenia and thrombocytopenia all resolved within 7 days of drug withdrawal. She had previously developed a neutropenia after receiving vancomycin. 

In a meta-analysis of randomized controlled comparisons of Unezolid and vancomycin for Gram-positive infections, rates of toxicity, including anemia, were similar [88 ]. Thrombocytopenia was more frequent with Unezolid and nephrotoxicity with vancomydn however, treatment duration was only about 9-12 days, which may have minimized hematological toxicity. 

Hematologic Possible vancomycin-induced thrombocytopenia occurred within 15 hours of treatment with vancomycin in a 61-year-... 

Kenney B, Tormey CA. Acute vancomycin-dependent immune thrombocytopenia as an anamnestic response. Platelets 2008 19(5) 379-83. 

Dilli D, Oguz SS, Dilmen U. A newborn with vancomycin-induced thrombocytopenia. Pharmacology 2008 82(4) 285-6. 

Renal insufficiency, usually reversible, is common after the procedure and commonly related to the use of nephrotoxic drugs such as ciclosporin, tacrolimus, vancomycin or amphotericin B. In a minority of instances dialysis may be required. Microangiopathic hemolysis and thrombocytopenia secondary to ciclosporin or tacrolimus may further... 

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